Schizophrenia: Difference between revisions

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'''For patient information click [[Schizophrenia (patient information)|here]]'''
'''For patient information click [[Schizophrenia (patient information)|here]]'''


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  Caption        = [[Eugen Bleuler]] (1857–1939) coined the term "Schizophrenia" in 1908 |
  Caption        = [[Eugen Bleuler]] (1857–1939) coined the term "Schizophrenia" in 1908 |
  Width          = 125 |
  Width          = 125 |
DiseasesDB = 11890 |
 
ICD10 = {{ICD10|F|20||f|20}} |
ICD9 = {{ICD9|295}} |
ICDO = |
OMIM = 181500 |
MedlinePlus    = 000928 |
MeshName = Schizophrenia |
MeshNumber = F03.700.750 |
}}  
}}  
{{Schizophrenia}}
{{Schizophrenia}}


{{CMG}}
{{CMG}}; {{AE}} {{JH}}, {{I.D.}}


==Overview==
{{SK}} Schizophrenic disorder; schizophrenic psychosis
<!--Para1: Definition, symptoms and diagnosis-->
'''Schizophrenia''', from the [[Ancient Greek|Greek]] roots ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "[[mind]]"), is a psychiatric diagnosis that describes a mental illness characterized by impairments in the [[perception]] or expression of reality, most commonly manifesting as auditory [[hallucination]]s, paranoid or bizarre [[delusion]]s or [[thought disorder|disorganized speech and thinking]] in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,<ref name="castle1991">Castle E, Wessely S, Der G, Murray RM (1991). "The incidence of operationally defined schizophrenia in Camberwell 1965–84," British Journal of Psychiatry 159: 790–794. PMID 1790446</ref> with approximately 0.4–0.6%<ref>Bhugra, D. (2005). [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960 The global prevalence of schizophrenia.] PLoS Medicine, 2 (5), 372–373. PMID 15916460</ref><ref name="fn_34">Goldner EM, Hsu L, Waraich P, Somers JM (2002). Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. ''Canadian Journal of Psychiatry'', 47(9), 833–43. PMID 12500753</ref> of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.


<!--Para2:lack of validity/controversies-->
==[[Schizophrenia overview|Overview]]==
Studies suggest that [[genetics]], early environment, [[neurobiology]] and psychological and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Due to the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. For this reason, [[Eugen Bleuler]] termed the disease ''the schizophrenias'' (plural) when he coined the name. Despite its [[etymology]], schizophrenia is not synonymous with [[dissociative identity disorder]], previously known as multiple personality disorder or split personality; in popular culture the two are often confused.


<!--Para3: Dopamine hypothesis and treatment-->
==[[Schizophrenia historical perspective|Historical Perspective]]==
Increased [[dopamine|dopaminergic activity]] in the [[mesolimbic pathway]] of the brain is a consistent finding. The mainstay of treatment is pharmacotherapy with [[antipsychotic]] medications; these primarily work by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.


<!--Para4: Impairment/chronicity and Comorbidity-->
==[[Schizophrenia classification|Classification]]==
The disorder is primarily thought to affect [[cognition]], but it also usually contributes to chronic problems with [[human behavior|behavior]] and [[emotion]]. People diagnosed with schizophrenia are likely to be diagnosed with [[Comorbidity|comorbid]] conditions, including [[clinical depression]] and [[anxiety disorders]]; the lifetime [[prevalence]] of [[substance abuse]] is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and [[life expectancy]] is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high [[suicide]] rate.<ref name="Brown_Barraclough_2000">Brown S, Inskip H, Barraclough B. (2000) Causes of the excess mortality of schizophrenia. ''Br J Psychiatry'', 177, 212-7. PMID 11040880</ref>


==Signs and symptoms==
==[[Schizophrenia pathophysiology|Pathophysiology]]==
A person experiencing schizophrenia may demonstrate symptoms such as [[Thought disorder|disorganized thinking]], auditory [[hallucination]]s, and [[delusion]]s. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are [[medical sign|sign]]s of [[catatonia]]. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a [[schizophreniform disorder]].<ref name="DSM-IV-TR">American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association. ISBN 0890420246. [http://www.behavenet.com/capsules/disorders/schiz.htm DSM-IV & DSM-IV-TR Schizophrenia criteria]</ref> No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.<ref name="DSM-IV-TR" />


Social isolation commonly occurs and may be due to a number of factors. Impairment in [[social cognition]] is associated with schizophrenia, as are the active symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and [[avolition]]. Many people diagnosed with schizophrenia avoid potentially stressful social situations that may exacerbate mental distress.<ref name="Freeman_BRT_2007">Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. (2007) Acting on persecutory delusions: the importance of safety seeking. ''Behaviour Research and Therapy'', 45 (1), 89–99. PMID 16530161</ref>
==[[Schizophrenia causes|Causes]]==


Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset. To minimize the impact of schizophrenia, much work has recently been done to identify and treat the [[prodrome|prodromal (pre-onset)]] phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.<ref name="Addington_et_al_2007">Addington J, Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R.  (2007) North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research. ''Schizophrenia Bulletin'', 33 (3), 665-72. PMID 17255119</ref> Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and [[dysphoria]] in the prodromal period,<ref name="ParnasJorgensen1989">Parnas J, Jorgensen A. (1989) Pre-morbid psychopathology in schizophrenia spectrum. ''British Journal of Psychiatry'', 155, 623–7.</ref> and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.<ref name="Amminger_et_al_2006">Amminger GP, Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD. (2006)  Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals. ''Schizophrenia Research'', 84 (1), 67–76. PMID 16677803</ref>
==[[Schizophrenia differential diagnosis|Differentiating Schizophrenia from other Diseases]]==


===Positive and negative symptoms===
==[[Schizophrenia epidemiology and demographics|Epidemiology and Demographics]]==
Schizophrenia is often described in terms of ''positive'' (or productive) and ''negative'' (or deficit) symptoms.<ref name="Sims_2002">Sims A (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edition). Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1</ref> Positive symptoms include [[delusion]]s, [[hallucination|auditory hallucinations]], and [[thought disorder]], and are typically regarded as manifestations of [[psychosis]]. Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat or [[blunted affect]] and [[emotion]], poverty of [[Speech communication|speech]] ([[alogia]]), [[anhedonia]], and lack of [[motivation]] ([[avolition]]). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in Schizophrenia especially in response to stressful or negative events.<ref>Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. ''Schizophr Res'', 1;69(1):7–14. PMID 15145465 </ref> A third symptom grouping, the ''disorganization syndrome'', is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.<ref name="Peralta_Cuesta_2001">Peralta V, Cuesta MJ. (2001) How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment. ''Schizophrenia Research'', 30, 49(3), 269-85. PMID 11356588</ref>


==Diagnosis==
==[[Schizophrenia risk factors|Risk Factors]]==
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a [[psychiatrist]], [[social worker]], [[clinical psychologist]] or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.


An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizophrenia, tests are carried out to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms. These include blood tests measuring [[Thyroid-stimulating hormone|TSH]] to exclude [[hypothyroidism|hypo-]] or [[hyperthyroidism]], [[Blood tests#Blood chemistry tests|basic electrolytes]] and serum [[calcium]] to rule out a metabolic disturbance, [[Complete blood count|full blood count]] including [[Erythrocyte sedimentation rate|ESR]] to rule out a systemic infection or chronic disease, and [[serology]] to exclude [[syphilis]] or [[HIV]] infection; two commonly ordered investigations are [[Electroencephalography|EEG]] to exclude [[epilepsy]], and a [[Computed tomography|CT scan]] of the head to exclude brain lesions. It is important to rule out a [[delirium]] which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness. There are several psychiatric illnesses which may present with psychotic symptoms other than schizophrenia. These include [[bipolar disorder]],<ref>Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328.</ref> [[borderline personality disorder]],<ref>McGlashan TH (1987) Testing DSM-III symptom criteria for schizotypal and borderline personality disorders. Archives of General Psychiatry, 44: 15–22.</ref> drug intoxication, brief drug-induced psychosis, and [[schizophreniform disorder]].
==[[Schizophrenia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==


Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication. These may include serum [[BSL]] if [[olanzapine]] has previously been prescribed, liver function tests if [[chlorpromazine]] or [[CPK]] to exclude [[neuroleptic malignant syndrome]]. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.
==Diagnosis==
 
The most widely used criteria for diagnosing schizophrenia are from the [[American Psychiatric Association|American Psychiatric Association's]] [[Diagnostic and Statistical Manual of Mental Disorders]], the current version being DSM-IV-TR, and the [[World Health Organization|World Health Organization's]] [[ICD|International Statistical Classification of Diseases and Related Health Problems]], currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian [[Kurt Schneider#First rank symptoms|first rank symptoms]] although, in practice, agreement between the two systems is high.<ref name="Jakobsen_et_al_2005">Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T (2005) Reliability of clinical ICD-10 schizophrenia diagnoses. ''Nordic Journal of Psychiatry'', 59 (3), 209-12. PMID 16195122</ref> The [[World Health Organization|WHO]] has developed the tool ''[[SCAN]] (Schedules for Clinical Assessment in Neuropsychiatry)'' which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.
 
===DSM IV-TR Criteria===
To be diagnosed with schizophrenia, a person must display:<ref name="DSM-IV-TR" />
 
*'''Characteristic symptoms''': Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated)
** [[delusion]]s
** [[hallucination]]s
** disorganized speech (e.g., frequent derailment or incoherence; speaking in abstracts). See [[thought disorder]].
** grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or [[Catatonia|catatonic]] behavior
** negative symptoms, i.e., [[affective flattening]] (lack or decline in emotional response), [[alogia]] (lack or decline in speech), or [[avolition]] (lack or decline in motivation).
 
:Note: Only one of these symptoms is required if delusions are bizarre or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other.
 
*'''Social/occupational dysfunction''': For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
 
*'''Duration''': Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if successfully treated).
 
Additional criteria are also given that exclude the diagnosis; thus schizophrenia cannot be diagnosed if symptoms of [[mood disorder]] or [[pervasive developmental disorder]] are present, or the symptoms are the direct result of a substance (e.g., abuse of a drug, medication) or a general medical condition.
 
===Subtypes===
Historically, schizophrenia in the West was classified into simple, [[catatonia|catatonic]], hebephrenic (now known as [[Disorganized schizophrenia|disorganized]]), and paranoid. The [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] contains five sub-classifications of schizophrenia:
 
* [[Paranoia#Use in psychiatry|'''paranoid type''']]: where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0)
* [[Disorganized schizophrenia|'''disorganized type''']]: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1)
* [[catatonia|'''catatonic type''']]: prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and [[waxy flexibility]] (DSM code 295.2/ICD code F20.2)
* '''undifferentiated type''': psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3)
* '''residual type''': where positive symptoms are present at a low intensity only (DSM code 295.6/ICD code F20.5)
 
The ICD-10 recognises a further two subtypes:
 
* '''post-schizophrenic depression''': a depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present (ICD code F20.4)
* '''simple schizophrenia''': insidious but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6)
 
===Diagnostic issues and controversies===
Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,<ref name="Bentall1992">Bentall RP (1992) ''Reconstructing Schizophrenia''. London: Routledge. ISBN 0415075246</ref><ref name="Boyle2002">Boyle M (2002) ''Schizophrenia: A Scientific Delusion?''. London: Routledge. ISBN 0415227186</ref> part of a larger [[Biopsychiatry controversy|criticism]] of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there is a spectrum or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on [[schizotypy]] and of a relatively high prevalence of psychotic experiences<ref name="fn_5">Verdoux H, van Os J (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. ''Schizophrenia Research'', 54(1&ndash;2), 59&ndash;65. PMID 11853979</ref><ref name="fn_65">LC, van Os J. (2001). The continuity of psychotic experiences in the general population. ''Clinical Psychology Review'', 21 (8),1125–41. PMID 11702510</ref> and often non-distressing delusional beliefs<ref name="fn_67">Peters ER, Day S, McKenna J, Orbach G(2005). Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI). ''Schizophrenia Bulletin'', 30, 1005–22. PMID 15954204</ref>  amongst the general public.<ref name="Johns_vanOs_2001">Johns LC, van Os J (2001) The continuity of psychotic experiences in the general population. ''Clinical Psychology Review'', 21 (8), 1125–41. PMID 11702510.</ref>
 
Another criticism is that the definitions used for criteria lack consistency;<ref name="David1999">David AS (1999) On the impossibility of defining delusions. ''Philosophy, Psychiatry and Psychology'', 6 (1), 17–20</ref> this is particularly relevant to the evaluation of [[delusion#Diagnostic issues and controversies|delusion]]s and [[thought disorder#Diagnostic issues and controversies|thought disorder]]. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness &mdash; a serious but nonspecific indicator".<ref name="fn_6">Tsuang MT, Stone WS, Faraone SV (2000). Toward reformulating the diagnosis of schizophrenia. ''American Journal of Psychiatry'', 157(7), 1041&ndash;1050. PMID 10873908</ref>
 
Perhaps because of these factors, studies examining the [[diagnosis]] of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously, David Rosenhan's 1972 study, published as ''[[Rosenhan experiment|On being sane in insane places]]'', demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable.<ref>Rosenhan D (1973). On being sane in insane places. ''Science'', 179, 250-8. PMID 4683124[http://www.stanford.edu/~kocabas/onbeingsane.pdf Full text as PDF]</ref> More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.<ref name="fn_7">McGorry PD, Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R (1995). Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. ''American Journal of Psychiatry'', 152 (2), 220&ndash;3. PMID 7840355</ref> This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.<ref name="fn_8">Read J (2004) Does 'schizophrenia' exist? Reliability and validity. In Read J, Mosher LR, Bentall RP (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6</ref>
 
In 2004 in Japan, the Japanese term for schizophrenia was changed from ''Seishin-Bunretsu-Byo'' (mind-split-disease) to ''Tōgō-shitchō-shō'' ([[integration disorder]]).<ref name="Sato">Sato M (2004). Renaming schizophrenia: a Japanese perspective. ''World Psychiatry'', 5(1), 53–5. PMID 16757998</ref> In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it.<ref name="schizophrenia_invalid">[http://news.bbc.co.uk/2/hi/health/6033013.stm Schizophrenia term use 'invalid'.] BBC News Online, ([[9 October]] [[2006]]). Retrieved on [[2007-05-16]]. </ref>
 
Alternatively, other proponents have put forward using the presence of specific [[neurocognitive deficit]]s to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as [[memory]], [[attention]], [[executive function]] and [[problem solving]]. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by [[antipsychotic]] medication), which seem to be the cause of most [[disability]] in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future.<ref name="GreenSchizophreniaBook">Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0393703347</ref>
 
The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the Soviet Union an additional sub-classification of [[sluggishly progressing schizophrenia]] was created. Particularly in the RSFSR (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment.<ref name="Wilkinson1986">Wilkinson G (1986) Political dissent and "sluggish" schizophrenia in the Soviet Union. ''Br Med J (Clin Res Ed)'', 293(6548), 641-2. PMID 3092963</ref> In 2000 there were similar concerns regarding detention and 'treatment' of practitioners of the Falun Gong movement by the Chinese government. This led the [[American Psychiatric Association|American Psychiatric Association's]] ''Committee on the Abuse of Psychiatry and Psychiatrists'' to pass a resolution to urge the [[World Psychiatric Association]] to investigate the situation in China.<ref name="Lyons2001">Lyons D (2001). Soviet-style psychiatry is alive and well in the People's Republic. ''British Journal of Psychiatry'', 178, 380–381. PMID 11282823</ref>
 
==Epidemiology==
Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females.<ref name="castle1991" /> Much rarer are instances of childhood-onset<ref name="Kumra_et_al_2001">Kumra S, Shaw M, Merka P, Nakayama E, Augustin R. (2001) Childhood-onset schizophrenia: research update. ''Canadian Journal of Psychiatry'', 46 (10), 923–30.</ref> and late- (middle age) or very-late-onset (old age) schizophrenia.<ref name="Howard_2005">Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London: Taylor and Francis. ISBN 18418439446</ref> The [[lifetime prevalence]] of schizophrenia, that is, the proportion of individuals expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002 [[systematic review]] of many studies, however, found a lifetime prevalence of 0.55%.<ref name="fn_34" /> Despite the received wisdom that schizophrenia occurs at similar rates throughout the world, its prevalence varies across the world,<ref name="Jablensky_et_al_1992">Jablensky A, Sartorius N, Ernberg G, et al. (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. ''Psychological Medicine Monograph Supplement'', 20, 1–97. PMID 1565705</ref> within countries,<ref name="Kirkbride_et_al_2006">Kirkbride JB, Fearon P, Morgan C, et al. (2006) Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings From the 3-center ÆSOP study. ''Archives of General Psychiatry'', 63, 250–258. PMID 16520429</ref> and at the local and neighbourhood level.<ref name="Kirkbride_et_al_2007">Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB. (2007) Neighbourhood variation in the incidence of psychotic disorders in Southeast London. ''Social Psychiatry and Psychiatric Epidemiology'', 42(6), 438-45. PMID 17473901</ref> One particularly stable and replicable finding has been the association between living in an urban environment and schizophrenia diagnosis, even after factors such as drug use, ethnic group and size of social group have been controlled for.<ref name="fn_19">Van Os J. (2004). Does the urban environment cause psychosis? ''British Journal of Psychiatry'', 184 (4), 287&ndash;288. PMID 15056569</ref> Schizophrenia is known to be a major cause of [[disability]]. In a 1999 study of 14 countries, active [[psychosis]] was ranked the third-most-disabling condition, after [[quadriplegia]] and [[dementia]] and before [[paraplegia]] and [[blindness]].<ref name="fn_35">Ustun TB, Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the WHO/NIH Joint Project CAR Study Group (1999). Multiple-informant ranking of the disabling effects of different health conditions in 14 countries. ''[[The Lancet]]'', 354(9173), 111&ndash;115. PMID 10408486</ref>
 
==Causes==
{{main|Causes of schizophrenia}}
[[Image:Schizophrenia PET scan.jpg|frame|Data from a [[Positron emission tomography|PET]] study<ref name="fn_25">Meyer-Lindenberg A, Miletich RS, Kohn PD, ''et al'' (2002). Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia. ''Nature Neuroscience'', 5, 267–71. PMID 11865311</ref> suggests that the less the [[frontal lobe]]s are activated (<font color="red">red</font>) during a [[working memory]] task, the greater the increase in abnormal [[dopamine]] activity in the [[striatum]] (<font color="green">green</font>), thought to be related to the [[neurocognitive deficit]]s in schizophrenia.]]
While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe [[bipolar disorder]] or [[Clinical depression|major depression]]), evidence suggests that genetic and environmental factors can act in combination to result in schizophrenia.<ref name="fn_12">Harrison PJ, Owen MJ. (2003). Genes for schizophrenia? Recent findings and their pathophysiological implications. ''[http://www.thelancet.com/ Lancet]'', 361(9355), 417&ndash;9. PMID 12573388</ref> Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.<ref name="fn_15">Day R, Nielsen JA, Korten A, Ernberg G, ''et al'' (1987). Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. ''Culture, Medicine and Psychiatry'', 11 (2), 123&ndash;205. PMID 3595169</ref> The idea of an inherent vulnerability (or ''diathesis'') in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model.<ref name="Corcoran_et_al_2003">Corcoran C, Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D. (2003) The stress cascade and schizophrenia: etiology and onset.
''Schizophr Bull'', 29 (4), 671-92. PMID 14989406</ref> The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model.
 
=== Genetic ===
Estimates of the [[heritability]] of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although [[twin studies]] have suggested a high level of heritability.<ref name="ODonovan_et_al_2003">O'Donovan MC, Williams NM, Owen MJ. (2003) Recent advances in the genetics of schizophrenia. ''Human Molecular Genetics'', 12 Spec No 2, R125-33. PMID 12952866</ref> It is likely that schizophrenia is a condition of complex inheritance, with several [[genes]] possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis.<ref name="fn_75">Owen MJ, Craddock N, O'Donovan MC. (2005). Schizophrenia: genes at last? ''Trends in Genetics'', 21(9), 518–25. PMID 16009449</ref> Recent work has suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as [[bipolar disorder]].<ref name="Craddock_et_al_2006">Craddock N, O'Donovan MC, Owen MJ. (2006) Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology. ''Schizophrenia Bulletin'', 32 (1), 9–16. PMID 16319375</ref> <ref name="Dalby_et_al_1986">Dalby JT, Morgan D, Lee M. (1986) Schizophrenia and mania in identical twin brothers.''Journal of Nervous and Mental Disease'',174,304-308. PMID 3701318</ref>
 
=== Prenatal ===
It is thought that causal factors can initially come together in early [[neurodevelopment]], including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the northern hemisphere).<ref name="fn_21">Davies G, Welham J, Chant D, Torrey EF, McGrath J. (2003). A [[systematic review]] and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia. ''Schizophrenia Bulletin'', 29 (3), 587&ndash;93. PMID 14609251</ref> There is now evidence that [[prenatal]] exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.<ref name="fn_73">Brown, A.S. (2006). Prenatal infection as a risk factor for schizophrenia. ''Schizophrenia Bulletin'', 32 (2), 200–2. PMID 16469941</ref>
 
=== Social ===
Living in an [[Urban area|urban]] environment has been consistently found to be a risk factor for schizophrenia.<ref name="vanOs_et_al_2005">van Os J, Krabbendam L, Myin-Germeys I, Delespaul P (2005) The schizophrenia envirome. ''Current Opinion in Psychiatry'', 18 (2), 141-5. PMID 16639166</ref> Social disadvantage has been found to be a risk factor, including poverty<ref>Mueser KT & McGurk SR. (2004) Schizophrenia. ''Lancet.'' June 19;363(9426):2063-72. PMID 15207959</ref> and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions.<ref name="Selten_et_al_2007">Selten JP, Cantor-Graae E, Kahn RS. (2007) Migration and schizophrenia. ''Current Opininion in Psychiatry'', 20 (2), 111-5. PMID 17278906</ref> Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.<ref name="Schenkel_et_al_2005">Schenkel LS, Spaulding WD, Dilillo D, Silverstein SM (2005). Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits. ''Schizophrenia Research'', 76(2–3), 273–286. PMID 15949659</ref><ref name="Janssen_et_al_2004">Janssen I, Krabbendam L, Bak M, Hanssen M, ''et al'' (2004). Childhood abuse as a risk factor for psychotic experiences. ''Acta Psychiatrica Scandinavica'', 109, 38–45. PMID 14674957</ref> Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk.<ref name="Bentall_et_al_2007"/><ref>
Subotnik, KL, Goldstein, MJ, Nuechterlein, KH, Woo, SM and Mintz, J. (2002) Are Communication Deviance and Expressed Emotion Related to Family History of Psychiatric Disorders in Schizophrenia? ''Schizophr Bull.'' 28(4):719-29 PMID 12795501</ref>
 
=== Substance use ===
The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to tease apart. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, [[paranoia]] and [[anhedonia]] are all considered to be core features.<ref name="Gregg_et_al_2007">Gregg L, Barrowclough C, Haddock G. (2007)  Reasons for increased substance use in psychosis. ''Clinical Psychology Review'', 27 (4), 494–510. PMID 17240501</ref> [[Amphetamine]]s trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the [[dopamine hypothesis of schizophrenia]]), amphetamines may worsen schizophrenia symptoms.<ref name="Laruelle_et_al_1996">Laruelle, M., Abi-Dargham, A., Van-Dyck, C. H., et al (1996) Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects. ''Proceedings of the National Academy of Sciences of the USA'', 93, 9235–9240. PMID 8799184 [http://www.pnas.org/cgi/content/abstract/93/17/9235 Full text]</ref> Schizophrenia can be triggered by heavy use of [[Psychedelics, dissociatives and deliriants|hallucinogenic]] or stimulant drugs.<ref>Mueser KT, Yarnold PR, Levinson DF, ''et al'' (1990). Prevalence of substance abuse in schizophrenia: demographic and clinical correlates. ''Schizophrenic Bulletin'', 16(1), 31–56. PMID 2333480</ref> One study suggests that [[cannabis (drug)|cannabis]] use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors that can cause psychosis.<ref name="fn_48">Arseneault L, Cannon M, Witton J, Murray RM (2004). Causal association between cannabis and psychosis: examination of the evidence. ''British Journal of Psychiatry'', 184, 110-7. PMID 14754822 [http://bjp.rcpsych.org/cgi/content/full/184/2/110 Full text]</ref>
 
=== Psychological ===
A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. [[Cognitive bias]]es that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external [[Attribution (psychology)|attributions]], impaired reasoning about social situations and [[Theory of mind|mental states]], difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration.<ref>Broome MR, Woolley JB, Tabraham P, Johns LC, ''et al'' (2005). What causes the onset of psychosis? ''Schizophr Res'', 79(1), 23–34. PMID 16198238</ref><ref> Lewis R (2004). Should cognitive deficit be a diagnostic criterion for schizophrenia? ''Journal of Psychiatry and Neuroscience'' March; 29(2): 102–113. PMID 15069464 </ref><ref>Brune M, Abdel-Hamid M, Lehmkamper C, Sonntag C (2007). Mental state attribution, neurocognitive functioning, and psychopathology: What predicts poor social competence in schizophrenia best? ''Schizophr Res.'' March 6 PMID 17346931</ref><ref>Sitskoorn MM, Aleman A, Ebisch SJH, Appels MCM, Khan RS (2004). Cognitive deficits in relatives of patients with schizophrenia: a meta-analysis. ''Schizophrenia Research'', Volume 71, Issue 2, Pages 285–295. PMID 15474899 </ref> Some cognitive features may reflect global [[neurocognitive deficit]]s in [[memory]], [[attention]], [[problem solving|problem-solving]], [[executive function]] or [[social cognition]], while others may be related to particular issues and experiences.<ref name="Kurtz_2005">Kurtz MM. (2005) Neurocognitive impairment across the lifespan in schizophrenia: an update. ''Schizophrenia Research'', 74 (1), 15–26. PMID 15694750</ref><ref name="Bentall_et_al_2007">Bentall RP, Fernyhough C, Morrison AP, Lewis S, Corcoran R. (2007) Prospects for a cognitive-developmental account of psychotic experiences. ''Br J Clin Psychol.'' Jun;46(Pt 2):155-73. PMID 17524210</ref> Despite a common appearance of "blunted affect", recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder.<ref>Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. ''Schizophr Res'', 1;69(1):7–14. PMID 15145465 </ref><ref>Horan WP, Blanchard JJ. (2003) Emotional responses to psychosocial stress in schizophrenia: the role of individual differences in affective traits and coping. ''Schizophr Res.'' April 1;60(2-3):271-83. PMID 12591589</ref><ref>Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B (2003). Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology. ''J Abnorm Psychol''. 112(1):92–9. PMID 12653417</ref> Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology.<ref>Birchwood M, Meaden A, Trower P, Gilbert P, Plaistow J (2000). The power and omnipotence of voices: subordination and entrapment by voices and significant others. ''Psychol Med''. Mar;30(2):337–44. PMID 10824654</ref><ref>Smith B, Fowler DG, Freeman D, ''et al'' (2006). Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. ''Schizophr Res''. Sep;86(1–3):181–8. PMID 16857346</ref><ref>Beck, AT (2004). [http://www.atypon-link.com/SPC/doi/abs/10.1891/jcop.18.3.281.65649?cookieSet=1&journalCode=jcop A Cognitive Model of Schizophrenia,] ''Journal of Cognitive Psychotherapy'', 18 (3), 281–288. Retrieved on [[2007-05-16]].</ref><ref>Bell V, Halligan PW, Ellis HD. (2006) Explaining delusions: a cognitive perspective. ''Trends Cogn Sci.'' May;10(5):219-26. PMID 16600666 </ref> Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.<ref>Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, Bebbington P. (2006) Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms. ''Schizophr Bull.'' Oct;32 Suppl 1:S24-31. PMID 16885206</ref>
 
=== Neural ===
[[Image:FMRI.jpg|thumb|[[Functional magnetic resonance imaging]] and other [[brain imaging]] technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.]]
 
Studies using [[neuropsychological test]]s and [[brain imaging]] technologies such as [[Functional magnetic resonance imaging|fMRI]] and [[Positron emission tomography|PET]] to examine functional differences in brain activity have shown that differences seem to most commonly occur in the [[frontal lobe]]s, [[hippocampus]], and [[temporal lobe]]s.<ref name="fn_31">Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7</ref> These differences have been linked to the [[neurocognitive deficit]]s often associated with schizophrenia.<ref name="Green2006">Green MF. (2006) Cognitive impairment and functional outcome in schizophrenia and bipolar disorder. ''Journal of Clinical Psychiatry'', 67, Suppl 9, 3–8. PMID 16965182</ref>
 
Particular focus has been placed upon the function of dopamine in the [[mesolimbic pathway]] of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the [[phenothiazines]], could reduce psychotic symptoms. An influential theory, known as the [[Dopamine hypothesis of schizophrenia]], proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called [[atypical antipsychotic]] medication) can be equally effective as older medication (called [[typical antipsychotic]] medication), but also affects [[serotonin]] function and may have slightly less of a [[dopamine]] blocking effect.<ref name="JonesPilowsky2002">Jones HM, Pilowsky LS (2002) Dopamine and antipsychotic drug action revisited. ''British Journal of Psychiatry'', 181, 271–275. PMID 12356650</ref>
 
Interest has also focused on the neurotransmitter [[glutamate]] and the reduced function of the [[NMDA receptor|NMDA glutamate receptor]] in schizophrenia. This has largely been suggested by abnormally low levels of glutamate receptors found in postmortem brains of people previously diagnosed with schizophrenia<ref name="fn_27">Konradi C, Heckers S. (2003). Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment. ''Pharmacology and Therapeutics'', 97(2), 153–79. PMID 12559388</ref> and the discovery that the glutamate blocking drugs such as [[phencyclidine]] and [[ketamine]] can mimic the symptoms and cognitive problems associated with the condition.<ref name="fn_59">Lahti AC, Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA. (2001). Effects of ketamine in normal and schizophrenic volunteers. ''Neuropsychopharmacology'', 25(4), 455–67. PMID 11557159</ref> The fact that reduced glutamate function is linked to poor performance on tests requiring [[frontal lobe]] and [[hippocampus|hippocampal]] function and that glutamate can affect [[dopamine]] function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia.<ref name="fn_28">Coyle JT, Tsai G, Goff D. (2003). Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia. ''Annals of the New York Academy of Sciences'', 1003, 318–27. PMID 14684455</ref> Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.<ref name="fn_60">Tuominen HJ, Tiihonen J, Wahlbeck K. (2005). Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis. ''Schizophr Res'', 72:225–34. PMID 15560967</ref>
 
There have also been findings of differences in the size and structure of certain brain areas in Schizohrenia, starting with the discovery of [[ventricular system|ventricular]] enlargement in those for whom negative symptoms were most prominent.<ref name="fn_29">Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. (1976). Cerebral ventricular size and cognitive impairment in chronic schizophrenia. ''Lancet'', 30;2 (7992), 924–6. PMID 62160</ref> However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia.<ref name="fn_30">Flashman LA, Green MF (2004). Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment. ''Psychiatric Clinics of North America'', 27 (1), 1–18, vii. PMID 15062627 </ref> However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia.
 
==Treatment and services==
{{main|Treatment of schizophrenia}}
[[Image:Chlorpromazine-3D-vdW.png|thumb|Molecule of [[chlorpromazine]], which revolutionized treatment of schizophrenia in the 1950s.]]
The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.<ref name="fn_63">van Os J, Burns T, Cavallaro R, ''et al'' (2006). Standardized remission criteria in schizophrenia. ''Acta Psychiatrica Scandinavica'', 113(2), 91–5. PMID 16423159</ref> <!-- and they are...?--> The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the [[PANSS|positive and negative syndrome scale]] (PANSS).<ref name="fn_68">Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. ''Schizophrenia Bulletin'', 13(2), 261–76. PMID 3616518</ref>
Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of [[chlorpromazine]].<ref name="Turner2007">{{cite journal | author=Turner T. | title=Unlocking psychosis | journal=Brit J Med | year=2007 | volume=334 | issue=suppl | pages=s7 }}</ref> A [[recovery model]] is increasingly adopted, emphasizing hope, empowerment and social inclusion.<ref name="Bellack06">Bellack AS. (2006) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. ''Schizophr Bull.'' Jul;32(3):432-42. PMID 16461575</ref>
 
Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or [[involuntary commitment]]). Long-term inpatient stays are now less common due to [[deinstitutionalization]], although can still occur.<ref name="BeckerKilian2006">Becker T, Kilian R. (2006) Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? ''Acta Psychiatrica Scandinavica Supplement'', 429, 9–16. PMID 16445476</ref> Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment<ref>McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. ''Am J Psychiatry.'' Mar;164(3):437–41. PMID 17329468</ref> and patient-led support groups.
 
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West.<ref name="fn_41">Kulhara P (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. ''European Archives of Psychiatry and Clinical Neuroscience'', 244(5), 227&ndash;35. PMID 7893767</ref>  The reasons for this effect are not clear, although cross-cultural studies are being conducted.
 
===Medication===
The mainstay of psychiatric treatment for schizophrenia is an [[antipsychotic]] medication.<ref name="fn_72">The Royal College of Psychiatrists & The British Psychological Society (2003). [http://www.nice.org.uk/download.aspx?o=289559 ''Schizophrenia. Full national clinical guideline on core interventions in primary and secondary care''] (PDF). London: Gaskell and the British Psychological Society. Retrieved on [[2007-05-17]].</ref> These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect.
[[Image:Risperdal tablets.jpg|thumb|left|150px|[[Risperidone]] (trade name '''Risperdal''') is a common [[atypical antipsychotic]] medication.]]
Though expensive, the newer [[atypical antipsychotic]] drugs are usually preferred for [[first-line treatment|initial treatment]] over the older [[typical antipsychotic]]s; they are often better tolerated and associated with lower rates of [[tardive dyskinesia]], although they are more likely to induce weight gain and [[obesity]]-related diseases.<ref name="fn_62">Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. ''[[The New England Journal of Medicine]]'', 353 (12), 1209–23. PMID 16172203</ref> Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.<ref name="Dickson_et_al_1995">Dickson RA, Dalby JT, Williams R, Edwards AL. (1995) Risperidone induced prolactin elevations in premenopausal women with schizophrenia. ''American Journal of Psychiatry'',152,1102-1103. PMID 7540803</ref>It remains unclear whether the newer antipsychotics reduce the chances of developing [[neuroleptic malignant syndrome]], a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to [[neuroleptic]] or antipsychotic drugs.<ref name="Ananth_et_al_2004">Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T. (2004) Neuroleptic malignant syndrome and atypical antipsychotic drugs. ''Journal of Clinical Psychiatry'', 65 (4), 464-70. PMID 15119907</ref>
 
The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.<ref name="fn_36">Leucht S, Wahlbeck K, Hamann J, Kissling W (2003). New generation antipsychotics versus low-potency conventional antipsychotics: a [[systematic review]] and meta-analysis. ''[[The Lancet]]'', 361(9369), 1581–9. PMID 12747876</ref>
 
Response of symptoms to mediation is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics.<ref>{{cite journal | author = Meltzer HY | title = Treatment-resistant schizophrenia--the role of clozapine | journal = Current Medical Research and Opinion | volume = 14 | issue = 1 | pages = 1–20  | date = 1997 | pmid=9524789 }}</ref> Patients in this category may be prescribed [[clozapine]],<ref>{{cite journal | author = Wahlbeck K, Cheine MV, Essali A | title = Clozapine versus typical neuroleptic medication for schizophrenia | journal = The Cochrane Database of Systematic Reviews | volume = | issue = 2 | pages = | publisher = John Wiley and Sons, Ltd. | date = 2007 | pmid=10796289 | doi = 10.1002/14651858.CD000059 | id = ISSN 1464-780X}}</ref> a medication of superior effectiveness but several potentially lethal side effects including [[agranulocytosis]] and [[myocarditis]].<ref>{{cite journal | author = Haas SJ, Hill R, Krum H  | title = Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993–2003 | journal = Drug Safety | volume = 30 | pages = 47–57 | date = 2007 | pmid=17194170 }}</ref> Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients. <ref>{{cite journal |author = Lee M, Dickson RA, Campbell M, Oliphant J, Gretton H, Dalby JT. |title = Clozapine and substance abuse in patients with schizophrenia |journal = Canadian Journal of Psychiatry |volume = 43 |pages = 855-856 |date = 1998 }}</ref> For other patients who are unwilling or unable to take medication regularly, long-acting [[Typical antipsychotic#Depot injections|depot]] preparations of antipsychotics may be given every two weeks to achieve control. America and Australia are two countries with [[Outpatient commitment|laws]] allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Nevertheless, some findings indicate that in the longer-term many individuals do better without taking antipsychotics.<ref>Harrow M, Jobe TH. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. ''J Nerv Ment Dis.'' May;195(5):406-14. PMID 17502806</ref>
 
===Psychological and social interventions===
[[Psychotherapy]] is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training.<ref>Moran, M (2005). [http://pn.psychiatryonline.org/cgi/content/full/40/22/24-b Psychosocial Treatment Often Missing From Schizophrenia Regimens.] ''Psychiatr News'' [[November 18]] [[2005]], Volume 40, Number 22, page 24. Retrieved on [[2007-05-17]].</ref>
 
[[Cognitive behavioral therapy]] (CBT) is used to reduce symptoms and improve related issues such as [[self-esteem]], social functioning, and insight. Although the results of early trials were inconclusive,<ref name="fn_38">Cormac I, Jones C, Campbell C (2002). Cognitive behaviour therapy for schizophrenia. ''Cochrane Database of [[systematic review]]s'', (1), CD000524. PMID 11869579</ref> more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.<ref name="fn_39">Zimmermann G, Favrod J, Trieu VH, Pomini V (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. ''Schizophrenia Research'', 77, 1–9. PMID 16005380</ref> Another approach is cognitive remediation therapy, a technique aimed at remediating the [[neurocognitive deficit]]s sometimes present in schizophrenia. Based on techniques of [[neuropsychological rehabilitation]], early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by [[fMRI]].<ref name="fn_40">Wykes T, Brammer M, Mellers J, ''et al'' (2002). Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. ''British Journal of Psychiatry'', 181, 144–52. PMID 12151286</ref> A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.<ref>Hogarty GE, Flesher S, Ulrich R, Carter M, ''et al'' (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. ''Arch Gen Psychiatry.'' Sep;61(9):866–76.PMID 15351765</ref>
 
Family Therapy or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term.<ref>McFarlane WR, Dixon L, Lukens E, Lucksted A (2003). Family psychoeducation and schizophrenia: a review of the literature. ''J Marital Fam Ther.'' Apr;29(2):223–45. PMID 12728780 </ref><ref>Glynn SM, Cohen AN, Niv N (2007). New challenges in family interventions for schizophrenia. '' Expert Rev Neurother.'' Jan;7(1):33–43. PMID 17187495</ref><ref>Pharoah F, Mari J, Rathbone J, Wong W. (2006) [http://www.cochrane.org/reviews/en/ab000088.html Family intervention for schizophrenia] Cochrane Database of Systematic Reviews, Issue 4</ref> Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject.<ref>{{cite book | author = Jones, S., Hayward, P. | title = Coping with Schizophrenia: A Guide for Patients, Families and Caregivers | publisher = Oneworld Pub. | date = 2004 | location = Oxford, England | id = ISBN 1-85168-344-5}}</ref><ref>{{cite book | last = Torrey | first = EF | authorlink = E. Fuller Torrey | title = Surviving Schizophrenia: A Manual for Families, Consumers, and Providers (5th Edition) | publisher = HarperCollins | date = 2006 | id = ISBN 0-06-084259-8}}</ref> There is also some evidence for benefits from social skills training, although there have also been significant negative findings.<ref>Kopelowicz A, Liberman RP, Zarate R (2006). Recent advances in social skills training for schizophrenia. ''Schizophr Bull.'' 2006 Oct;32 Suppl 1:S12–23. PMID 16885207 </ref><ref>American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients With Schizophrenia. Second Edition.</ref> Some studies have explored the possible benefits of music therapy and other creative therapies.<ref>Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S (2006). Music therapy for in-patients with schizophrenia: Exploratory randomised controlled trial. ''The British Journal of Psychiatry.'' Nov;189:405–9. PMID 17077429  [http://bjp.rcpsych.org/cgi/content/abstract/189/5/405 Full text available.] </ref><ref>Ruddy R, Milnes D. (2005) [http://www.cochrane.org/reviews/en/ab000088.html Art therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 4</ref><ref>Ruddy RA, Dent-Brown K. (2007) [http://www.cochrane.org/reviews/en/ab005378.html Drama therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 1.</ref>
 
===Other===
[[Electroconvulsive therapy]] is not considered a [[first line treatment]] but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present,<ref>{{cite journal |author=Greenhalgh J, Knight C, Hind D, Beverley C, Walters S |year=2005 |month=March |title= Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies.|journal= Health Technol Assess.|volume= 9|issue=9 |pages=1-156 |url=http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15774232 (abstract) |accessdate= 2007-06-17}}</ref> and is recommended for use under [[National Institute for Health and Clinical Excellence|NICE]] guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise.<ref>{{cite web |url=http://www.nice.org.uk/page.aspx?o=TA059 |title= The clinical effectiveness and cost effectiveness of electroconvulsive Therapy (ECT) for depressive illness, schizophrenia, catatonia and mania.|accessdate=2007-06-17 |author= National Institute for Health and Clinical Excellence|year= 2003|month=April |publisher= National Institute for Health and Clinical Excellence|language= English}}</ref> [[Psychosurgery]] has now become a rare procedure and is not a recommended treatment for schizophrenia.<ref name="Mashour_et_al_2005">Mashour GA, Walker EE, Martuza RL. (2005) Psychosurgery: past, present, and future. ''Brain Research: Brain Research Reviews'', 48 (3), 409-19. PMID 15914249</ref>
 
An unconventional approach is the use of omega-3 fatty acids, with one study finding some benefits from their use as a dietary supplement.<ref>Peet M, Stokes C (2005). Omega-3 fatty acids in the treatment of psychiatric disorders. Drugs, 65(8), 1051–9. PMID 15907142</ref>
 
Service-user led movements have become integral to the recovery process in [[Europe]] and [[United States|America]]; groups such as the [[Hearing Voices Network]] and the [[Paranoia Network]] have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for [[mental illness]] or [[mental health]], they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.<ref name="Goering_et_al_2006">Goering P, Durbin J, Sheldon CT, Ochocka J, Nelson G, Krupa T. Who uses consumer-run self-help organizations?
''American Journal of Orthopsychiatry'', 76 (3), 367-73. PMID 16981815</ref>
 
==Prognosis==
Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions.<Ref>Harrison G, Hopper K, Craig T, Laska E, Siegel C, Wanderling J, Dube KC, Ganev K, Giel R, an der Heiden W, Holmberg SK, Janca A, Lee PW, León CA, Malhotra S, Marsella AJ, Nakane Y, Sartorius N, Shen Y, Skoda C, Thara R, Tsirkin SJ, Varma VK, Walsh D, Wiersma D. (2001)  Recovery from psychotic illness: a 15- and 25-year international follow-up study. ''Br J Psychiatry.'' Jun;178:506-17. PMID 11388966</ref> One retrospective study found that about a third of people made a full recovery, about a third showed improvement but not a full recovery, and a third remained ill.<ref name="fn_42">Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. ''American Journal of Psychiatry'', 144(6), 727–35. PMID 3591992</ref> A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years.<ref name="fn_43">Robinson DG, Woerner MG, McMeniman M, Mendelowitz A, Bilder RM (2004). Symptomatic and functional recovery from a first episode of schizophrenia or [[schizoaffective disorder]]. ''American Journal of Psychiatry'', 161, 473–479. PMID 14992973</ref> A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes.<ref>Harvey, C.A., Jeffreys, S.E., McNaught, A.S., Blizard, R.A., King, M.B.(2007) [http://isp.sagepub.com/cgi/content/abstract/53/4/340 The Camden Schizophrenia Surveys III: Five-Year Outcome of a Sample of Individuals From a Prevalence Survey and the Importance of Social Relationships.]  ''International Journal of Social Psychiatry,'' Vol. 53, No. 4, 340-356</ref> Rates are not always comparable across studies because an exact definition of what constitutes recovery has not been widely accepted, although standardized criteria have been suggested.<ref name="fn_63" />
 
The [[World Health Organization]] conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, United Kingdom, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),<ref name="fn_44">Hopper K, Wanderling J (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. ''Schizophrenia Bulletin'', 26 (4), 835–46. PMID 11087016</ref> despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.
 
Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning.<ref name="Davidson_Glashan_1997">Davidson L, McGlashan TH. (1997) The varied outcomes of schizophrenia. ''Canadian Journal of Psychiatry'', 42 (1), 34–43. PMID 9040921</ref><ref name="Lieberman_et_al_1996">Lieberman JA, Koreen AR, Chakos M, Sheitman B, Woerner M, Alvir JM, Bilder R. (1996) Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia. ''Journal of Clinical Psychiatry'', 57 Suppl 9, 5–9. PMID 8823344</ref> Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high 'Expressed Emotion' or 'EE' by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.<ref name="fn_70">Bebbington PE, Kuipers E (1994). The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. ''Psychological Medicine'', 24, 707–718. PMID 7991753</ref>
 
===Mortality===
In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than [[substance abuse]], [[personality disorder]], [[myocardial infarction|heart attack]] and [[stroke]].<ref name="fn_45">Hannerz H, Borga P, Borritz M (2001). Life expectancies for individuals with psychiatric diagnoses. ''Public Health'', 115 (5), 328–37. PMID 11593442</ref> There is a high [[suicide]] rate associated with schizophrenia; a recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime.<ref name="fn_46">Radomsky ED, Haas GL, Mann JJ, Sweeney JA (1999). Suicidal behavior in patients with schizophrenia and other psychotic disorders. ''American Journal of Psychiatry'', 156(10), 1590&ndash;5. PMID 10518171</ref> <ref name="fn_128">Williams R, Dalby JT. Eds. (1989). Depression in Schizophrenics. New York: Plenum Publishing.</ref>Another study suggested that 10% of persons with schizophrenia die by suicide.<ref name="fn_47">Caldwell CB, Gottesman II. (1990). Schizophrenics kill themselves too: a review of risk factors for suicide. ''Schizophrenia Bulletin'', 16(4), 571&ndash;89. PMID 2077636</ref> Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs.<ref name="Brown_Barraclough_2000" />
 
==Screening and prevention==
There are no reliable markers for the later development of schizophrenia although research is being conducted into how well a combination of genetic risk plus non-disabling psychosis-like experience predicts later diagnosis.<ref name="Cannon_et_al_2007">Cannon TD, Cornblatt B, McGorry P. (2007) Editor's Introduction: The Empirical Status of the Ultra High-Risk (Prodromal) Research Paradigm. ''Schizophrenia Bulletin'', 33 (3), 661–4. PMID 17470445</ref> People who fulfil the 'ultra high-risk mental state' criteria, that include a family history of schizophrenia plus the presence of transient or self-limiting psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one year.<ref name="Drake_Lewis_2005">Drake RJ, Lewis SW. (2005) Early detection of schizophrenia. ''Current Opinion in Psychiatry'', 18 (2), 147–50. PMID 16639167</ref> The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown schizophrenia.<ref name="vanOs_Delespaul_2005">Van Os J, Delespaul P. (2005)  Toward a world consensus on prevention of schizophrenia. ''Dialogues in Clinical Neuroscience'', 7 (1), 53–67.</ref> However, the treatment of people who may never develop schizophrenia is controversial, in light of the side-effects of antipsychotic medication; particularly with respect to the potentially disfiguring [[tardive dyskinesia]] and the rare but potentially lethal [[neuroleptic malignant syndrome]].<ref name="Haroun_et_al_2006">Haroun N, Dunn L, Haroun A, Cadenhead KS. (2006) Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. ''Schizophrenia Bulletin'', 32 (1), 166–78. PMID 16207892. [http://schizophreniabulletin.oxfordjournals.org/cgi/content/full/32/1/166 Full text]</ref> The most widely used form of preventative health care for schizophrenia takes the form of public education campaigns that provide information on risk factors, early detection and treatment options.<ref name="Hafner_et_al_2004">Hafner H, Maurer K, Ruhrmann S, ''et al''. (2004) "Early detection and secondary prevention of psychosis: facts and visions". ''European Archives of Psychiatry and Clinical Neuroscience'', 254 (2), 117–28. PMID 15146341</ref>
 
== Popular views and misconceptions ==
Views held by the public about mental disorders, including schizophrenia, may not coincide with available evidence or with the views held by some mental health professionals.
 
=== Treatment ===
Some psychiatrists believe patients can be discouraged by friends or family members from taking prescribed medication because of the latters' non-biological views of mental disorders.<ref Name="PsychNews00">American Psychiatric Association. Americans Still Cling to Myths About Mental Illness, Survey Finds. ''Psychiatric News.'' December 7, 2001 Volume 36 Number 23 [http://pn.psychiatryonline.org/cgi/content/full/36/23/14-a Full text]</ref> There is scientific difference of opinion about the use of medication in schizophrenia.<ref>Gould, JE. (2006) Ethical Considerations in Medication-Free Research with Schizophrenia Patients: An Expert Interview with William T. Carpenter, Jr., M.D. ''Medscape Psychiatry & Mental Health'' 2006:11(2) [http://www.medscape.com/viewarticle/546243 Full text available]</ref> Consumers' views on treatment and recovery may differ from those of mental health professionals.<ref name="Bellack06"/>
 
=== Violence ===
The relationship between violent acts and schizophrenia is a contentious topic. One survey found that 61% of Americans judged individuals with schizophrenia as likely to commit an act of interpersonal violence, while only 17% thought such an act likely to be committed by a person described as "troubled".<ref>Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S (1999). The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. ''[[American Journal of Public Health]].'' Sep;89(9):1339–45. PMID 10474550</ref>
 
Research on violence indicates that the percentage of people with schizophrenia who commit violent acts is several times higher than the percentage of people without any disorder, but lower than is found for disorders such as alcoholism, and the difference is reduced or not found in same-neighbourhood comparisons when related factors are taken into account, notably sociodemographic variables and substance misuse.<ref name="Walsh02">Walsh E, Buchanan A, Fahy T (2002). Violence and schizophrenia: examining the evidence. ''British Journal of Psychiatry.'' 2002 Jun;180:490–5. PMID 12042226</ref><ref name="Stuart 03">Stuart, H (2003). Violence and mental illness: an overview. ''World Psychiatry.'' June; 2(2): 121–124. PMID 16946914 [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1525086 Full text,] Retrieved on [[2007-05-17]].</ref><ref>Steadman HJ, Mulvey EP, Monahan J, ''et al'' (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. ''Archives of General Psychiatry.'' May;55(5):393–401. PMID 9596041</ref><ref>Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, ''et al'' (2006). A national study of violent behavior in persons with schizophrenia. ''Archives of General Psychiatry.'' May;63(5):490–9. PMID 16651506</ref><ref>Swanson JW, Holzer CE, Ganju VK, Jono RT. (1990) Violence and Psychiatric Disorder in the Community: Evidence From the Epidemiologic Catchment Area Surveys ''Hosp Community Psychiatry'' 41:761-770, July 1990 PMID 2142118</ref> Studies have indicated that 5 to 10% of those charged with murder in Western countries have a schizophrenia spectrum disorder.<ref name="Mullen 06">Mullen PE (2006). Schizophrenia and violence: from correlations to preventive strategies. ''Advances in Psychiatric Treatment'' 12: 239–248. [http://apt.rcpsych.org/cgi/content/abstract/12/4/239 Full text available,] Retrieved on [[2007-05-17]].</ref><ref name="fn_52">Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004). Homicide and mental illness in New Zealand, 1970–2000. ''British Journal of Psychiatry'', 185, 394–8. PMID 15516547</ref><ref name="fn_53">Fazel S, Grann M (2004). Psychiatric morbidity among homicide offenders: a Swedish population study. ''American Journal of Psychiatry'', 161(11), 2129–31. PMID 15514419</ref>
 
The occurrence of [[psychosis]] in schizophrenia has sometimes been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent, but have focused on delusional jealousy, perception of threat and command hallucinations. It has been proposed that a certain type of individual with schizophrenia may be most likely to offend, characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset substance misuse and offending prior to diagnosis.<ref name= "Mullen 06"/>
 
A consistent finding is that individuals with a diagnosis of schizophrenia are often the victims of violent crime—at least 14 times more often than they are perpetrators.<ref>Brekke JS, Prindle C, Bae SW, Long JD (2001). Risks for individuals with schizophrenia who are living in the community. ''Psychiatric Services.'' Oct;52(10):1358–66. PMID 11585953</ref><ref name="fn_55">Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J (2005). Victimization of patients with schizophrenia and related disorders. ''Australia and New Zealand Journal of Psychiatry'', 39(3), 169-74. (1), 187–9. PMID 15701066</ref> Another consistent finding is a link to substance misuse, particularly alcohol,<ref name="fn_51">Walsh E, Gilvarry C, Samele C, ''et al'' (2004). Predicting violence in schizophrenia: a prospective study. ''Schizophrenia Research'', 67(2–3), 247-52. PMID 14984884</ref> among the minority who commit violent acts. Violence by or against individuals with schizophrenia typically occurs in the context of complex social interactions within a family setting,<ref> Solomon PL, Cavanaugh MM, Gelles RJ (2005). Family Violence among Adults with Severe Mental Illness. ''Trauma, Violence, & Abuse'', Vol. 6, No. 1, 40–54. PMID 15574672[http://tva.sagepub.com/cgi/content/abstract/6/1/40 Full text available.]</ref> and is also an issue in clinical services<ref>Chou KR, Lu RB, Chang M (2001). Assaultive behavior by psychiatric in-patients and its related factors. ''Journal of Nursing Research.'' Dec;9(5):139–51. PMID 11779087</ref> and in the wider community.<ref>Logdberg B, Nilsson LL, Levander MT, Levander S (2004). Schizophrenia, neighbourhood, and crime. ''Acta Psychiatrica Scandinavica,'' 110(2) Page 92. PMID 15233709 [http://www.blackwell-synergy.com/links/doi/10.1111/j.1600-0047.2004.00322.x/abs/ Full text available,] Retrieved on [[2007-05-16]]</ref>
 
==Alternative approaches==
An approach broadly known as the [[anti-psychiatry]] movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness.<ref name="Cooper1969">Cooper D (1969) ''The Dialectics of Liberation''. London: Penguin Books Ltd. ISBN 0140210296</ref> Psychiatrist [[Thomas Szasz]] argued that psychiatric patients are not ill rather individuals with unconventional thoughts and behavior that make society uncomfortable.<ref name="Szasz1984">Szasz T (1984) ''The Myth of Mental Illness: Foundations of a Theory of Personal Contact (revised edition''. New York: Harper and Row. ISBN 0060911514</ref> He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of social control. According to this view, "schizophrenia" does not actually exist but is merely a form of [[Social constructionism|social construction]], created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists R. D. Laing, [[Silvano Arieti]], Theodore Lidz and Colin Ross<ref> {{cite book | last = Colin | first = Ross | title = Schizophrenia: Innovations in Diagnosis and Treatment | publisher = Haworth Press | date = 2004 | isbn = 0789022699}} </ref> have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were notable in valuing the ''content'' of [[psychosis|psychotic]] experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations.<ref>R.D. Laing's and Aaron Esterson. ''Sanity, Madness and the Family'' (1964)</ref> In the books ''Schizophrenia and the Family'' and ''The Origin and Treatment of Schizophrenic Disorders'' Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's ''Interpretation of Schizophrenia'' won the 1975 scientific National Book Award in the United States.
 
The concept of schizophrenia as a result of civilization has been developed further by psychologist [[Julian Jaynes]] in his 1976 book ''The Origin of Consciousness in the Breakdown of the Bicameral Mind''; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness.<ref name="Jaynes1976">Janyes J (1976) ''The Origin of Consciousness in the Breakdown of the Bicameral Mind''. Houghton Mifflin. ISBN 0395207290</ref> This would take the form of a "[[bicameral mind]]" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. Researchers into [[shamanism]] have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman;<ref name="fn_57">Polimeni J, Reiss JP (2002). How shamanism and group selection may reveal the origins of schizophrenia. ''Medical Hypothesis'', 58(3), 244–8. PMID 12018978</ref> the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the [[altered state of consciousness|altered states of consciousness]] psychiatrists label as illness. [[Psychohistory|Psychohistorians]], on the other hand, accept the psychiatric diagnoses. However, unlike the current [[Biological psychiatry|medical model of mental disorders]] they argue that [[Trauma model of mental disorders#Psychohistory Table|poor parenting in tribal societies]] causes the shaman's schizoid personalities.<ref>[[Lloyd deMause|DeMause, Lloyd]], "The seven stages of historical personality" in ''The Emotional Life of Nations'' (Karnac, 2002). Available at [http://primal-page.com/ps2.htm primal-page.com,] Retrieved on [[2007-05-17]].</ref> Speculation regarding primary and important religious figures as having schizophrenia abound. Commentators such as Paul Kurtz and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.<ref>Kurtz, Paul (1986). ''The Transcendental Temptation: A Critique of Religion and the Paranormal'' (Prometheus Books) ISBN 0-87975-645-4</ref>
 
Psychiatrist Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for [[language]].<ref name="fn_56">Crow TJ (1997). Schizophrenia as failure of hemispheric dominance for language. ''Trends in Neurosciences'', 20(8), 339–343. PMID 9246721</ref> Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down.
 
The [[Soteria]] model is an alternative treatment to institutionalization and early use of antipsychotics.<ref>{{cite journal | author = Bola JR, Mosher LR | title = Treatment of Acute Psychosis Without Neuroleptics: Two-Year Outcomes From the Soteria Project | journal = The Journal of Nervous and Mental Disease | publisher = Lippincott Williams & Wilkins, Inc | volume = 191  | pages = 219–229 | date = April 2003 | url = http://www.moshersoteria.com/bola.pdf | format=PDF | pmid=12695732|accessdate=2007-06-13}}</ref> It is described as a milieu-therapeutic recovery method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment."<ref name="mosh99">Mosher LR (1999). "Soteria and Other Alternatives to Acute Psychiatric Hospitalization: A Personal and Professional Review." Journal of Nervous and Mental Disease, 187, 142–149.</ref>
 
A branch of [[alternative medicine]] that deals with schizophrenia is known as [[orthomolecular psychiatry]]. Some argue that schizophrenia can be treated effectively with doses of Vitamin B-3 ([[Niacin]]).<ref>Hoffer and Walker, ''Orthomolecular Nutrition''. Keats Publishing, 1978</ref> The body's adverse reactions to [[gluten]] are [[gluten-free, casein-free diet|implicated in some alternative theories]]. This theory—discussed by one author in three British journals in the 1970s<ref> Dohan FC (1970). Coeliac disease and schizophrenia. ''Lancet'', 1970 April 25;1(7652):897–8. PMID 4191543<br />*Dohan FC (1973). Coeliac disease and schizophrenia. ''British Medical Journal'', 3(5870): 51–52. PMID 4740433<br />* Dohan FC (1979). Celiac-type diets in schizophrenia. '' Am J Psychiatry'', 1979 May;136(5):732–3. PMID 434265</ref>—is unproven. A 2006 literature review suggests that gluten may be a factor for a subset of patients with schizophrenia, but further study is needed to confirm the association between gluten and schizophrenia.<ref name="Kalaydjian_AE"> Kalaydjian AE, Eaton W, Cascella N, Fasano A (2006). The gluten connection: the association between schizophrenia and celiac disease. ''Acta Psychiatr Scand.'' 2006 Feb;113(2):82–90. PMID 16423158</ref>
 
==History==
Descriptions of schizophrenia-like symptoms date to 2000 BC in the ''Book of Hearts''—part of the ancient [[Ebers papyrus]]. However, study of the ancient Greek and Roman literature shows that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia.<ref name="fn_1>Evans K, McGrath J, Milns R. (2003). Searching for schizophrenia in ancient Greek and Roman literature: a [[systematic review]]. ''Acta Psychiatrica Scandanavica'', 107(5), 323&ndash;330. PMID 12752027</ref>
 
[[Image:Emil Kraepelin.png|left|thumb|[[Emil Kraepelin]] (1856–1926) refined the concept of [[psychosis]].]]
Although a broad concept of [[Insanity|madness]] has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by [[Emil Kraepelin]] in 1893. He was the first to make a distinction in the psychotic disorders between what he called ''[[dementia praecox]]'' (early dementia—a term first used by psychiatrist [[Bénédict Morel]] [1809–1873]) and [[bipolar disorder|manic depression]]. Kraepelin believed that ''dementia praecox'' was primarily a disease of the brain,<ref name="fn_2">Kraepelin E. (1907) ''Text book of psychiatry (7th ed)'' (trans. A.R. Diefendorf). London: Macmillan.</ref> and particularly a form of [[dementia]], distinguished from other forms of dementia, such as [[Alzheimer's disease]], which typically occur later in life.<ref name="fn_49">"''Conditions in Occupational Therapy: effect on occupational performance.''" ed. Ruth A. Hansen and Ben Atchison (Baltimore: Lippincott, Williams & Williams, 2000), 54&ndash;74. ISBN 0-683-30417-8</ref>
 
The word ''schizophrenia''—which translates roughly as "splitting of the mind" and comes from the Greek roots ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "[[mind]]")<ref>{{cite journal |author=Kuhn R; tr. Cahn CH |title=Eugen Bleuler's concepts of psychopathology |journal=Hist Psychiatry |volume=15 |issue=3 |date=2004 |pages=361–6 |doi=10.1177/0957154X04044603 |pmid=15386868}}</ref>—was coined by [[Eugen Bleuler]] in 1908 and was intended to describe the separation of function between [[personality psychology|personality]], [[thought|thinking]], [[memory]], and [[perception]]. Bleuler described the main symptoms as 4 ''A'''s: flattened ''Affect'', ''Autism'', impaired ''Association'' of ideas and ''Ambivalence''.<ref name="fn_78"> Stotz-Ingenlath G. (2000). Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911. ''Medicine, Health Care, and Philosophy'', 3(2), 153–9. PMID 11079343</ref> Bleuler realized that the illness was not a [[dementia]] as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.
 
The term ''schizophrenia'' is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term ''schizophrenia'' (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet [[T. S. Eliot]] in 1933.<ref name="fn_3">Turner T. (1999) 'Schizophrenia'. In [[G. E. Berrios]] and [[Roy Porter|R. Porter]] (eds) ''A History of Clinical Psychiatry''. London: Athlone Press. ISBN 0-485-24211-7</ref>
 
In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to [[eugenics]] in many countries. Hundreds of thousands were [[Sterilization (surgical procedure)|sterilized]], with or without consent—the majority in Nazi Germany, the United States, and Scandinavian countries.<ref name="fn_76">Allen GE. (1997). The social and economic origins of genetic determinism: a case history of the American Eugenics Movement, 1900–1940 and its lessons for today. ''Genetica'', 99, 77–88. PMID 9463076</ref><ref name="fn_77">Read J, Masson J. (2004) Genetics, eugenics and mass murder. In J. Read, L.R. Mosher, R.P. Bentall (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6</ref> Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "[[Action T4]]" program.<ref name="Lifton_2000">Lifton RJ. (2000) ''The Nazi Doctors: Medical Killing and the Psychology of Genocide''. Basic Books. ISBN 0465049052</ref>
 
The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.<ref name="Wing1971">Wing JK (1971) International comparisons in the study of the functional psychoses. ''British Medical Bulletin'', 27 (1), 77–81. PMID 4926366</ref> This was partly due to looser diagnostic criteria in the US, which used the [[DSM-II]] manual, contrasting with Europe and its [[ICD-9]]. This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the [[DSM-III]].<ref name="Wilson1993">Wilson M. (1993) DSM-III and the transformation of American psychiatry: a history. ''American Journal of Psychiatry'', 150 (3), 399–410. PMID 8434655</ref>
 
===Cultural references===
The book and film ''A Beautiful Mind'' chronicled the life of John Forbes Nash, a Nobel-Prize-winning mathematician who was diagnosed with schizophrenia. The Marathi film ''Devrai'' (Featuring Atul Kulkarni) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India, shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and lots of patience of the close relatives of the patient. Other factual books have been written by relatives on family members; Australian journalist Anne Deveson told the story of her son's battle with schizophrenia in ''Tell me I'm Here'',<ref>{{cite book  | last = Deveson  | first = Anne  | authorlink = Anne Deveson | title = Tell Me I'm Here | publisher = Penguin | date = 1991 | pages = | id = ISBN 0-14-027257-7}}</ref> later made into a movie.
 
In Mikhail Bulgakov's ''Master and Margarita'' the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book ''The Eden Express'' by Mark Vonnegut accounts his struggle into schizophrenia and his journey back to sanity.


==References==
[[Schizophrenia diagnostic criteria|Diagnostic Criteria]] | [[Schizophrenia history and symptoms|History and Symptoms]] | [[Schizophrenia physical examination|Physical Examination]] | [[Schizophrenia laboratory findings|Laboratory Findings]] | [[Schizophrenia other diagnostic studies|Other Diagnostic Studies]]
{{reflist|2}}


==Further reading==
==Treatment==
<!-- Please only include material which addresses schizophrenia in general, rather than specific aspects, or related topics -->
<div class="references-small">
* [[Richard Bentall|Bentall, R.]] (2003) ''Madness explained: Psychosis and Human Nature''. London: Penguin Books Ltd. ISBN 0-7139-9249-2
* [[James Fallon|Fallon, James H.]] et al. (2003) The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems. ''Clinical Neuroscience Research'' 3:77–107. Available at [http://dx.doi.org/10.1016/S1566-2772(03)00022-7 Elsevier article locater.]
* Green, M.F. (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7
* Keen, T. M. (1999) Schizophrenia: orthodoxy and heresies. A review of alternative possibilities. ''Journal of Psychiatric and Mental Health Nursing'', 1999, 6, 415–424. PMID 10818864
*[[Theodore Lidz|Lidz, Theodore]], [[Stephen Fleck]] & Alice Cornelison, ''Schizophrenia and the Family''. International Universities Press, 1965. ISBN 978-0823660018
* Noll, Richard (2007) ''The Encyclopedia of Schizophrenia and Other Psychotic Disorders, Third Edition'' ISBN 0-8160-6405-9
* [http://www.openthedoors.com/english/index.html Open The Doors - information on global programme to fight stigma and discrimination because of Schizophrenia. The World Psychiatric Association (WPA)]
* Read, J., Mosher, L.R., Bentall, R. (2004) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6. A critical approach to biological and genetic theories, and a review of social influences on schizophrenia.
* [http://www.sciam.com/article.cfm?chanID=sa006&articleID=000EE239-6805-1FD5-A23683414B7F0000 Scientific American Magazine (January 2004 Issue) Decoding Schizophrenia]
* Shaner, A., Miller, G. F., & Mintz, J. (2004). Schizophrenia as one extreme of a sexually selected fitness indicator. ''Schizophrenia Research'', 70(1), 101–109. PMID 15246469[http://www.unm.edu/~gfmiller/new_papers/shaner%20miller%202004%20schizo.pdf Full text (PDF),] Retrieved on [[2007-05-17]].
* [[Thomas Szasz|Szasz, T.]] (1976) ''Schizophrenia: The Sacred Symbol of Psychiatry''. New York: Basic Books. ISBN 0-465-07222-4
* [[Viktor Tausk|Tausk, V.]] : "Sexuality, War, and Schizophrenia: Collected [[Psychoanalytic]] Papers", Publisher: Transaction Publishers 1991, ISBN 0-88738-365-3 (On the Origin of the 'Influencing Machine' in Schizophrenia.)
* Wiencke, Markus (2006) ''Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie''. In David Kim (ed.), ''Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity'' (pp. 123–155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5
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[[Schizophrenia medical therapy|Medical Therapy]] | [[Schizophrenia psychotherapy|Psychotherapy]] | [[Schizophrenia prevention|Prevention]] | [[Schizophrenia social impact|Social Impact]] |  [[Schizophrenia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Schizophrenia future or investigational therapies|Future or Investigational Therapies]]


[[ar:فصام]]
==Case Studies==
[[bs:Shizofrenija]]
[[Schizophrenia case study one|Case #1]]
[[bg:Шизофрения]]
[[ca:Esquizofrènia]]
[[cs:Schizofrenie]]
[[da:Skizofreni]]
[[de:Schizophrenie]]
[[et:Skisofreenia]]
[[es:Esquizofrenia]]
[[eo:Skizofrenio]]
[[fa:روان‌گسیختگی]]
[[fr:Schizophrénie]]
[[gl:Esquizofrenia]]
[[ko:정신분열증]]
[[hr:Shizofrenija]]
[[io:Skizofrenio]]
[[id:Skizofrenia]]
[[ia:Schizophrenia]]
[[is:Geðklofi]]
[[it:Schizofrenia]]
[[he:סכיזופרניה]]
[[kl:Skizofrenii]]
[[ku:Şîzofrenî]]
[[la:Morbus dissidentiae phreneticae]]
[[lt:Šizofrenija]]
[[hu:Skizofrénia]]
[[ms:Skizofrenia]]
[[nl:Schizofrenie]]
[[ja:統合失調症]]
[[no:Schizofreni]]
[[pl:Schizofrenia]]
[[pt:Esquizofrenia]]
[[ro:Schizofrenie]]
[[qu:Waq'akay]]
[[ru:Шизофрения]]
[[simple:Schizophrenia]]
[[sk:Schizofrénia]]
[[sr:Схизофренија]]
[[sh:Shizofrenija]]
[[fi:Skitsofrenia]]
[[sv:Schizofreni]]
[[tr:Şizofreni]]
[[uk:Шизофренія]]
[[ur:انفصام]]
[[zh:精神分裂症]]


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Latest revision as of 00:05, 30 July 2020


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Synonyms and keywords: Schizophrenic disorder; schizophrenic psychosis

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